Indications for surgery
Surgical formation of the oral vestibule is performed in cases of anatomical and post-traumatic defects that hinder high-quality prosthetics.
Key indications include:
- Presence of a shallow oral vestibule.
- Scar contractures of the mucous membrane (often of traumatic origin and predominantly found on the mandible).
- Need to form an anatomical contour after the removal of lobular fibromas.
Technique with a stents stent and autograft
The classical approach involves the use of a forming stents stent and a free skin autograft. The main drawback of the method is the difficulty in selecting a donor site: the tissue must match in physical characteristics and strictly contain no hair follicles.
Features of the surgery on the mandible:
- The stents stent is wrapped with skin so that the wound surface of the flap faces outward (for tight contact with the bed).
- Sutures are positioned so that the appliance can be easily removed later.
- The stent is placed into the wound, and the mucosal edges are approximated with interrupted sutures.
- For rigid fixation, circummandibular sutures (surrounding the mandible) are applied and tied over the facial skin, placing a gauze ball underneath for protection against cutting through.
Features on the maxilla: To form the vestibule and fix the flap, a special palatal plate is used, which is rigidly fixed to the bone with screws.
The stent is removed on the 10th day, but the patient continues to wear it as a removable former until the permanent denture is created (to prevent scar deformation).
Silicone complex vestibuloplasty
The technique by A.V. Shchipsky et al. (2007) is highly technological, yields predictable results, and has absolutely no contraindications. Simultaneous intervention on both jaws is permitted, and the surgery can be performed on an outpatient basis.
The silicone material is characterized by bioinertness, microporosity (acts as a moist dressing), transparency (allows the physician to visually monitor healing), and the ability to optimize regeneration without interfering with epithelialization.
Course of the surgical stage:
- Under anesthesia, scars are excised, and the vestibule is given the desired shape and depth.
- The wound is isolated with a silicone membrane (protective function), sutured peripherally with interrupted sutures.
- A silicone pad is placed on top (forming function) and secured with percutaneous mattress-type sutures.
- Sterile buttons are placed under the knots of the percutaneous sutures on the skin of the chin or lip — they protect the skin from deformation better than gauze pads and simplify care.
After 2 weeks, the silicone complex is removed. After this, a provisional immediate denture must be fabricated immediately (or the old one relined, preferably by the laboratory method). The denture base must strictly correspond to the new vestibule — this is a mandatory condition for the final stabilization of tissue parameters.
Correction of the oral floor level
In pronounced atrophy of the alveolar part of the mandible, the topography of the soft tissues is disrupted. The anatomical basis of the problem is that the mylohyoid muscle (m. mylohyoideus) and geniohyoid muscle (m. geniohyoideus) shift upward and end up at the level of the alveolar ridge. Deformations often occur simultaneously on the vestibular and lingual sides.
To solve the problem, the classical Trainer method is used, as well as modifications by Wassmund or Obwegeser. The modifications allow vestibuloplasty and floor correction to be performed simultaneously (but only if the alveolar part is partially preserved).
Stages of combined surgery:
- Detachment of the periosteum and apical displacement (downward) of the formed flaps.
- Fixation of soft tissues with sutures in the new position.
- Closure of the exposed bone with a free skin autograft.
- Fixation of the graft with circumferential sutures.
Briefly: answers to topical questions
What are the classic surgical techniques of vestibuloplasty?
Classic surgical techniques of vestibuloplasty include a number of eponymous operations and modern modifications. The main methods include:
- Kazanjian technique (Lip Switch) — use of a repositioned mucosal flap of the lip.
- Edlan technique (Edlan) — modification of the Kazanjian method using the periosteum instead of the mucosa to close the wound on the lip.
- Obwegeser technique (Obwegeser) — submucosal vestibuloplasty to increase the depth of the oral vestibule.
- Wassmund technique — used to eliminate scar contractures.
- Trainer method — the classical method for correcting the oral floor level.
Vestibuloplasty using a silicone complex is also used.
What are the general and local contraindications to vestibuloplasty?
The sources describe only local contraindications for individual vestibuloplasty techniques; general contraindications are not specified.
- Shortened lip — is a strict contraindication for submucosal vestibuloplasty according to Obwegeser.
- Alveolar process height less than 15 mm — limits the application of the Kazanjian technique, as it requires a preserved bone height of at least 15 mm.
At the same time, vestibuloplasty using a silicone complex is characterized by the absolute absence of contraindications.
What specific complications may arise in the postoperative period after vestibuloplasty?
In the postoperative period after vestibuloplasty, the development of a number of specific complications is possible, depending on the chosen technique.
- Relapse — return to the initial state, which is characteristic of the Obwegeser submucosal technique.
- Bone resorption — increased process of alveolar bone resorption, especially when detaching the periosteum in modifications of the Kazanjian technique.
- Scarring — risk of scar formation and the creation of a narrow vestibule shape with the Kazanjian technique.
- Graft complications — tendency to retraction, aesthetic defect, and the risk of hair growth in the oral vestibule when using a skin autograft.
To remember the properties of the silicone material, use the acronym PORB (in Russian): Transparency (healing control), Optimization of regeneration (does not interfere with epithelialization), Working microporosity (moist dressing effect), Bioinertness (absence of adverse reactions).
Class and exam questions
Can the surgery be performed on both jaws simultaneously?
Yes, simultaneous intervention on the upper and lower jaws is permitted when using the silicone complex. The stents stent technique usually does not imply this.
What are sterile buttons used for during the fixation of the silicone bolster?
Buttons are placed under the knots of percutaneous sutures. Unlike gauze rolls, they more reliably prevent facial skin deformation and provide better conditions for postoperative care.
When are sutures and appliances removed?
The Stent's impression compound insert with a skin autograft is removed on the 10th day. The silicone complex (membrane and bolster) is removed approximately in 2 weeks, once the wound is epithelialized.
Why is prosthetics initiated immediately after removing the silicone complex?
The shaping denture (or relined old one) helps to finally stabilize the parameters of the recreated vestibule. This is a mandatory condition before fabricating a permanent removable denture.
What else to study on this topic
- Methods of surgical fixation of skin autografts on the maxilla using a palatal plate
- Comparative characteristics of direct and laboratory methods for relining removable dentures
- Topographic anatomy of m. mylohyoideus and m. geniohyoideus in pronounced mandibular atrophy
- Indications and limitations of the classical Trainer method
- Features of tissue mobilization in the Wassmund and Obwegeser modifications
Master the entire topic in the course "Surgical Dentistry"
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- Complete study guide on "Vestibuloplasty" and 866 more pages on the subject
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Other topics in "Chapter 16. Surgical Preparation of the Oral Cavity for Prosthetic Treatment (A.V. Shchipsky)"
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